Policy claim

Querist : Anonymous (Querist) 14 November 2011 This query is : Resolved
Please help me...
I had made a medical policy with one insurance policy... but they are giving denial letters to my claim... as they are saying on their own that the disease which i got treated in hospital was not after the inception of the policy but it is a 4 years old disease and it started before the inception of the policy ? is there any rule as to the policyinsuring company on their own deny my claim.... and how should i recover my claim

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Sailesh Kumar Shah Online

(Expert) 14 November 2011
Insurance company has valid ground to refuse claim if disease before the inception of the policy. Check policy document, it would mentioned.

If disease incurred, after policy inception, then insurance company can't deny subject to policy taken by you.

Rajeev Kumar (Expert) 14 November 2011
Mr.shah is right

Devajyoti Barman (Expert) 14 November 2011
This is quite a common resort for the insurance Companies to evade claim.
First clarify whether the beneficiary of the Policy was aware of such disease.

If the answer is no then even if the disease is indeed a pre existing one, the insurance company can not avoid the claim. The judicial precedents is quite unanimous in this respect.

File a complaint u/s 12 of Consumer Protection Act.

ajay sethi (Expert) 14 November 2011
you have made a claim on basi of insurance policy . the case of insurance company is its preexisting disease.

when you wnt for operation did you inform the hospital that you had this disease for last 4 years .

generally when any claim is made insurance companies investigate whether you have surpressed any material factor . if you have given false information , surpressed pre existing illness insurance company is justifed in refusing to make payment .

check the provision sof your plicy . it generally contains a clause that insurance company wont make payment for pre existing disease if not disclosed at time of taking policy

prabhakar singh (Expert) 15 November 2011
All said all done.

What goes in practice i am disclosing.These insurers have agents who are given hefty commissions by them to promote the sale of
their policies in market because policies framed have almost negative returns and buyers of policies do not understand economics behind them.

Then very strangely while the fact is that it is the agent of insurance company who causes the sale of policy to buyer,the papers are so designed that in law the buyer becomes the PROPOSER and company becomes the ACCEPTER,a virtual false against the truth.Even doctors who check
up are their own.So at that point of time
the buyer is never allowed to understand
any of the ticklish but when unfortunately
a claim arises they start bungling on this and that score.

We need to address this problem from this angel also pleading equity for beneficiaries,as despite a regulator in existence nothing has changed and people in the country are mostly illiterate to understand these deceptively designed business.

Guest (Expert) 21 November 2011
Of course, several cases get rejected on such type of reasons quoted by the company. Agents selling insurance policies do not make picture clear to the prospective insurants at the time of proposals.

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